修回日期: 2008-09-12
接受日期: 2008-09-17
在线出版日期: 2008-10-28
食管支架最初用于食管癌的姑息治疗, 提高晚期食管癌的生活质量. 随着各种新型支架的出现, 学者们逐渐尝试将食管支架用于食管良性狭窄的治疗, 并取得了一定的临床效果. 本文就常用食管支架在良恶性食管狭窄中的应用作一综述.
引文著录: 裴庆山, 刘吉勇. 食管支架研究进展. 世界华人消化杂志 2008; 16(30): 3410-3415
Revised: September 12, 2008
Accepted: September 17, 2008
Published online: October 28, 2008
Esophageal stents were used initially in the palliative treatment of esophageal carcinoma to improve the life quality of the patients in the advanced stage. Along with the appearance of many new kinds of esophageal stents, esophageal stents have been used in the management of the benign esophageal strictures, and clinical effectiveness has been made. This article reviews the application of the esophageal stents in the benign and malignant esophageal strictures.
- Citation: Pei QS, Liu JY. Advances in research of esophageal stents. Shijie Huaren Xiaohua Zazhi 2008; 16(30): 3410-3415
- URL: https://www.wjgnet.com/1009-3079/full/v16/i30/3410.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v16.i30.3410
食管支架的产生是对食管癌治疗不断探索的产物, 早期食管癌虽然手术可以完全切除, 但是由于早期食管癌症状不明显, 大多食管癌患者只有在晚期出现进食梗阻时才就诊被发现, 此时已失去手术机会, 因此如何解决晚期食管癌患者的进食问题, 改善其晚期的生活质量, 成为临床医生着手解决的问题. 自1983年, Frimberger[1]首先报道了采用金属支架治疗食管狭窄获得成功, 开创了食管癌支架治疗的新时代, 为食管狭窄治疗提供了新思路. 最初的支架只是用于解除梗阻, 并取得了一定临床效用, 随着技术的革新改进, 1991年韩国的Song et al[2]将金属食管支架表面被以硅酮膜后, 支架的应用也变得越来越广, 现支架已广泛应用于良恶性食管狭窄、食管瘘口的修补等食管疾病. 早期的金属无覆膜支架因其出血、穿孔、无法取出等并发症多, 已基本退出临床. 现在所用食管支架的类型可谓多种多样的, 每一种支架的优缺点也不尽相同, 下面就临床常用食管支架作一综述.
食管支架类型较多, 按照支架材料的不同, 可以将现在临床常用食管支架分为以下: (1)不锈钢金属支架: 属于这一类的支架主要有Wallstent支架及Z型支架等, 前者是由不锈钢合金丝构成网眼管状结构, 此种支架抗外压力强, 不易变形, 但是释放时应精确定位, 释放后无法调整位置和回收, 针对食管下段及贲门的特殊结构设计有FlamingoWallstent支架[3]. Z型食管支架主要有COOK公司、WILSON-COOK公司生产. 江苏西格玛公司的Z型支架国内已广泛应用, 此类支架的不锈钢丝呈"Z"形排列, 支撑力强, 钢性骨架之间采用软连接, 使支架质感柔软, 具有良好的纵向顺应性, 可以适应弯曲变形的病变部位. 支架在骨架内外覆有高强度医用硅橡胶薄膜, 使肿瘤组织不易长入, 并可耐腐蚀, 且上下口有较软的硅橡胶裙边以减少对组织机械性刺激, 减少支架再狭窄的发生, 因支架上端安装有回收线可回收, 可用于良性狭窄的治疗. (2)记忆金属支架: 镍钛记忆金属有良好的形状记忆功能和优良的弹性, 在4℃以下时, 可任意缩小变形而无弹性, 随着温度的升高, 支架逐渐恢复弹性, 发挥持久扩张作用. 支架与组织生物相容性好, 扩张后的支架与病变组织之间保持良好的顺应性并可维持较好的径向张力, 另外, 支架的柔软性好, 患者的异物感较轻. Ultraflex、Esophacoil Instent支架都属于这一类, 国内常州、南京等多家公司都已生产此种支架, 现临床应用也较普遍. 早期的Ultraflex支架移位率高[4], 后经改进, 将支架两端改为喇叭口, 并安装回收线, 使其移位发生减少并可以回收. Esophacoil Instent支架由单一扁平镍钛金属丝紧密螺旋环绕而成, 采用捆绑式输送器, 现此种支架临床应用较少[5-6]. (3)聚酯塑料支架: Polyflex塑料食管支架美国、德国多家公司生产, 国外应用较多[7-11], 国内未见有报道使用. 此种支架采用聚酯塑料编制网眼, 内覆硅酮膜. 支架上口开口较大, 呈喇叭口状, 以减少移位, 支架中段及远端开口内径相同. 钡线置于支架两端及中间以利于X-ray检查定位, 为方便内镜下检查对应钡线位置支架采用蓝色标记. 此种支架可回收, 支架两端息肉形成再狭窄的几率较小, 但是移位发生率较高.
食管支架最初的研制目的就是解决不能手术治疗的食管癌性狭窄, 重建通道, 解决患者的营养问题, 提高晚期食管癌患者的生活质量, 随着支架技术的发展, 覆膜支架的产生, 食管支架已越来越多的应用于各种食管瘘如食管纵隔瘘、食管气管瘘等的封堵, 并取得了很好的疗效. 已有大量的文献报道[12-28], 食管支架对恶性食管狭窄所致的吞咽困难及食管瘘的治疗是安全、有效的, 这些支架中有金属支架, 也有塑料支架. 但他也只作为一种姑息治疗方法, 提高晚期患者的生活质量[12,15,28], 还未见有明显延长患者生存时间的报道. 近年来, 有学者将放射性粒子安装在食管支架上制成新型支架, 并已有动物实验[29-30]已及临床应用[31]报道其可行性及安全性. 在Guo et al[31]的报道中, 将53例病例分为两组, 27例放置放射性支架, 26例放置普通支架作为对照组, 结果1 mo时两组吞咽障碍评分都显著改善, 但2 mo时放射性支架组吞咽评分明显好于对照组. 并且, 放射性支架组患者的平均生存时间及生存时间中位数分别达到8.3 mo及7 mo, 较对照组的3.5 mo及4 mo, 均存在显著性差异. 由此可见, 放射性食管支架不仅缓解了患者的进食状况, 而且起到了一定的放疗的作用, 能够一定程度的延长患者的生存时间. 此种支架有望成为不能手术治疗的食管癌患者的新的治疗方法.
食管良性狭窄主要有食管癌术后吻合口狭窄、化学烧伤、反流性食管炎所致狭窄、贲门失迟缓症等. 食管支架在恶性狭窄姑息治疗中的临床效果较为确切, 但是在良性食管狭窄中的应用需权衡支架的治疗作用与其并发症之间的利弊关系. 当然在某些食管良性疾病如术后吻合口瘘、穿孔等的治疗中食管支架的使用可使患者获益[32-36], 但是考虑到支架的远期并发症如息肉形成再狭窄、支架移位、难以取出、出血等, 多数学者认为食管良性疾病放置支架治疗需谨慎[37-39]. 目前来说, 还没有一种十分令人满意的食管支架用于良性食管狭窄, 下面综述食管支架在食管良性狭窄治疗中的应用. (1)可回收覆膜金属支架: Song et al[40]在研究覆膜金属支架时发现支架2 mo后脱落的患者没有形成新的狭窄, 由此推测良性狭窄治疗中支架放置的最佳时间为4-8 wk, 并设计了可回收金属支架. 最初设计采用不锈钢覆膜支架, 后来改为镍钛合金支架, 在其一系列的研究中[40-43], 取得了较好的治疗效果, 即使支架移除后出现再狭窄的患者对后续(球囊扩张或二次支架置入等)治疗也较前敏感, 效果较放支架前要好. 在文献[42]中由于48%的再狭窄率, 有12例患者没有达到8 wk的预期治疗时间, 并且作者发现支架上口或下口由于组织增生形成的狭窄多在放支架后2-6 wk产生, 因此建议每两周行胃镜或钡餐检查, 一旦发现再狭窄随时移除支架, 否则移除支架将变得困难. 为减少支架带来的再狭窄发生, 国内学者[44]曾用个体化全覆膜食管支架减小支架上口喇叭口的大小或无喇叭口, 并增加两端硅胶膜软裙边的设计, 结果没有再狭窄的发生, 但是, 随之而来的是支架移位增加. (2)聚酯塑料支架: 塑料支架是国外应用较多的可回收食管支架, 已有大量的文献报道[7-11,45-49]其在食管良恶性狭窄, 食管气管瘘, 术后吻合口瘘等中取得了良好的治疗效果, 较之金属支架, 支架两端息肉形成再狭窄及胸痛、出血等并发症的出现几率要小的多, 但是其存在的突出的问题是支架移位. 文献[45-48]中支架移位率分别达到了24%、30%、22%、37%, 在Evrard et al[49]的报道中竟高达57%. 支架移位后大都可以通过钳子或套圈将其取出, 但也有难以去除而不得不借助于外科手术的. (3)国内学者Cheng et al曾使用暂时性镍钛金属部分覆膜支架治疗食管良性狭窄及贲门失弛缓症患者, 此种支架口近端1-2 cm为无覆膜区, 支架上口为大喇叭, 借此以增加支架的稳定性, 减少移位[50-52]. 为了防止肉芽组织长入支架上口无覆膜处导致无法取出, 此种支架需在置入3-7 d时取出. 通过比较支架置入前后及取出后食管的内径, 吞咽评分及支架置入的主要并发症, 并作了中远期疗效分析, 发现此种支架较之球囊扩张术及永久性支架治疗良性狭窄的中远期疗效要好. (4)可降解食管支架: 由于金属及塑料支架用于食管良性狭窄的都存在明显弊端, 较多学者将目光投向了可降解材料食管支架[53-55]. 医用可降解材料中应用最广的当属聚乳酸, 其作为骨折内固定材料、手术缝合线、药物控释等早已用于临床, 且有血管内支架的运用. 聚乳酸的良好组织相容性, 无毒性及可降解性早已临床证实, 聚乳酸食管支架的开发有望解决食管支架置入后的诸多并发症如息肉形成再狭窄, 出血感染等, 且此种支架不用取出可自行降解, 减少了取出时支架对食管的损伤. 最早的聚乳酸可降解食管支架的报道见于日本学者Tanaka et al[56], 在另一位日本学者Saito et al[57]最近的研究中, 13例患者经聚乳酸可降解支架治疗, 随访7 mo至2年没有发现再狭窄. 但是其中有7例患者是ESD术后预防性的置入支架, 只有6例是用于食管狭窄的球囊扩张后的后续治疗, 因此作为食管良性狭窄的一种治疗手段还有待大量病例的研究. 此种支架自我扩展性及机械强度较差, 以致其放置过程不同于金属支架, 较为复杂, 且置入后还需别针固定于食管壁上以防其移位脱落. 由于聚乳酸的降解, 10/13的支架在10-21 d即出现脱位, 这一时间对食管狭窄的治疗是否足够也有待进一步证实.
总之, 食管支架用于良性狭窄的治疗效果还不理想, 需综合考虑其利弊关系, 可降解材料食管支架有望成为一种理想的支架, 但是其应用前景还有待较多临床资料的证实.
(1)胸骨后疼痛: 是支架置入后最常见的并发症, 其发生主要与支架对食管壁的缓慢扩张撕裂及支架置入后胃食管反流增加有关, 大都可以通过抑酸、止痛药物治疗后缓解, 有报道发生严重胸痛发生率可达20%左右[43,58]此时需要强止痛药或移除支架. 胃食管反流多见于支架放置于食管下段或贲门处病变的患者, 自许国铭 et al[59]研发了防反流食管金属支架后胃食管反流的发生得到了有效控制, 现食管下段的狭窄病变多放置此种支架. (2)支架移位和脱落: 多与患者进食不当及支架本身有关. 患者在支架置入后1-2 wk内最好以流质半流质食物为主, 且注意少食多餐, 对于镍钛合金支架应忌过冷、过热食物以防其变形脱落. 不同支架移位发生率不同, 金属支架移位相比塑料支架移位发生率较低[60], 可能与支架本身的机械扩张力有关. 且同为金属支架, 因支架编制方式或金属材料不同其支架移位率也会有不同[61-62]. 支架移位后多采用内镜下调整或移除支架, 对于不能移除的可考虑外科剖腹或腹腔镜手术. (3)管腔再狭窄: 无覆膜或部分覆膜支架再狭窄率高, 多是由于肿瘤组织长入网眼所致. 全覆膜支架常发生于支架上下两端, 由食管蠕动与上下口之间的剪切力所导致的组织增生形成再狭窄. 再狭窄发生后可放置新的支架[63-64], 也可通过内镜下氩气刀或激光[64]等处理. (4)其他: 如出血、穿孔、食管气管瘘等. 出血多为少量出血, 可术后予止血药预防, 大出血也可见报道, 但都少见. 穿孔、食管瘘发生率虽较低, 但在大量的病例统计中也可以经常遇到[43,64].
食管支架在食管狭窄中的治疗已成为一种有效的方法, 现行食管支架类型较多, 各个公司生产的支架也不尽相同, 今后支架的发展方向应着力减少其并发症的发生. 放射性支架已逐渐用于临床, 在姑息治疗的同时起到了一定的杀伤肿瘤细胞的作用, 但是其疗效随访及其会不会加重组织损伤使出血穿孔几率增加等都有待进一步研究. 虽然多种食管支架已用于良性狭窄的治疗, 也取得了一定的治疗效果, 但是仍需研发新型支架克服现行支架的弊端, 较多学者将目光投向可降解材料, 但在其持续扩张力及机械弹性等方面还有待改进, 其广泛应用还有待时日.
食管支架最初应用于晚期食管癌梗阻患者的姑息治疗, 随着技术的革新及支架制作工艺的逐渐完善, 现食管支架也较多用于食管良性狭窄患者, 但是食管良性狭窄的治疗思路与晚期食管癌的治疗思路是不同的, 因此食管良恶性狭窄支架的选用也不一样.
欧希龙, 副教授, 东南大学中大医院消化科.
较多学者认为用于食管良性狭窄的理想支架, 可能有赖于可降解材料, 但是其持续扩张力及机械弹性等方面还有待改进, 还需较多的动物及临床实验的证实.
本文系统总结食管良性狭窄中的支架应用, 并指出各种支架应用中存在的问题及有待改进之处.
本文综述了食管支架在良恶性狭窄中应用的最新进展, 并总结各种支架在应用时的优缺点, 对今后食管支架的改进有参考价值.
本文介绍了食管支架各种类型及适应证, 尤其是食管性狭窄的各种支架的选择、放置方法及其存在问题, 内容具有新颖性, 具有重要临床意义.
编辑:李军亮 电编:何基才
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